Provider Demographics
NPI:1568718476
Name:PRAKASH, PRANAV (MD)
Entity Type:Individual
Prefix:
First Name:PRANAV
Middle Name:
Last Name:PRAKASH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 N SHADELAND AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2600 GREENBUSH ST
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47904-2477
Practice Address - Country:US
Practice Address - Phone:765-448-8000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-29
Last Update Date:2021-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125060949207Q00000X
IN01075184A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000977223OtherANTHEM
IN201305970Medicaid
IN000001011883OtherANTHEM PROVIDER NUMBER UNDER TIN 35-2030653
IN000001011883OtherANTHEM PROVIDER NUMBER UNDER TIN 35-2030653
IN201305970Medicaid